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Transcript of Breast Cancer;
Back to Basics
Early puberty and late menupause.
Delayed 1st pregnancy.
Approach to Diagnosis; the Assessment Protocol
Mammography and ultrasound for patients = > 40 years.
Ultrasound for patients < 40 years with clinically benign or uncertain lesions (P2, P3).
Mammography should be performed in women below the age of 40 years for lesions, which are suspicious on clinical or ultrasound criteria P4/5 or U4/5.
Assessment of the axilla with US is Mandatory if cancer is suspected and at least FNA of any abnormal looking node is a MUST.
Most cancer affecting women worldwide.
In our practice, majority of patients present with advanced local or distant disease.
Why time of presentation matters?
Staging evaluation to define extent of cancer, presence of multifocal or multicentric cancer in ipsilateral breast or screening of the contralateral breast cancer at time of initial diagnosis.
Evaluation before and after neoadjuvent therapy.
Detection of additional disease in patients with mammografically dense breast.
Screening young patients with strong family Hx.
When to Proceed with Metastatic Workup?
Abdominal +/- pelvic diagnostic CT or MRI
: abdominal symptoms, abnormal physical examination, elevated ALP, liver enzymes.
Chest diagnostic CT
: pulmonary symptoms.
If clinical staging IIIA (T3, N1, M0)
: abd, chest CT and bone scan.
Up front or post op staging?
Primary or metastases.
Primary Invasive carcinoma:
Infiltrating ductal - 76 %
Invasive lobular - 8 %
Ductal/lobular - 7 %
Mucinous (colloid) - 2.4 %
Tubular - 1.5 %
Medullary - 1.2 %
Papillary - 1 %
Approach to Management
Concepts of Management
Local: WLE, mastectomy +\- RT.
Regional: None, Sentinel +\- AC (Levels 1,2 or 3).
Systemic: Chemotherapy, Hormone therapy, Herceptin.
Neo-adjuvant, adjuvant or palliative.
-BCS, with minimal of 2 mm radial margin, offering further surgery if the margin is less.
-RT is offered if breast is conserved.
-No nodal surgery is offered unless we'll go for mastectomy, or the patient have presented with a lump.
-Assessment of Hormonal receptors.
DCIS Management Cont.
Inflammatory Breast Cancer
Invasive breast cancer management
Early stage breast cancer
primary surgery (WLE or mastectomy) to the breast and regional nodes with or without radiation therapy (RT). Following definitive local treatment, adjuvant systemic therapy may be offered based on primary tumor characteristics.
Breast-conserving surgery (BCS, ie, WLE) plus radiation therapy (RT).
Its goals; survival equivalent of mastectomy, a cosmetically acceptable breast, and a low rate
of recurrence in the treated breast.
Criteria that preclude BCT include:
Large tumor size in relation to breast.
Presence of diffuse malignant-appearing calcifications on imaging (ie, mammogram or magnetic resonance imaging [MRI]).
Prior history of chest RT (eg, mantle radiation for Hodgkin disease).
Persistently positive margins despite attempts at re-excision.
Invasive Breast Cancer Management Cont..
Invasive Breast Cancer Management Cont..
A mastectomy is indicated for patients who are not candidates for BCT and those who prefer mastectomy.
The different types of mastectomy.
Malignant epithelial (Paget) cells infiltrate and proliferate in the epidermis, causing thickening of the nipple and the areolar skin.
Mastectomy and Sentinel node biopsy has always been the standard.
If the disease is localized, offer excision of nipple-areola complex followed by RT,(after assessment with MRI).
If co-existent / underlying disease, treat accordingly.
Breast Cancer in Pregnancy
Up front staging.
locoregional therapy (MRM+RT).
Axillary Staging and Management
Can we omit axillary clearance in in sentinal node +ve cases?
All patients with highly suspicious Mammogram should have axillary ultrasound scan with U S guided needle biopsy if abnormal nodes are detected.
Technitium and Blue dye is the ideal.
3-5 Nodes sampling is an accepted alternative.
The HOT – the
and the HARD.
Offer Axillary Nodes Dissection if preoperative assessment showed nodal involvement .
Consider pre Neo-adjuvant Sentinel node biopsy.
In the unusual situation of Node metastases with No obvious primary, mastectomy and Axillary Clearance is our preferred option (after assessment with MRI).
Axillary staging and management
A Breast Surgeon.
A Plastic Surgeon interested in Breast Surgery.
A Medical Oncologist with interest in Breast Ca.
A Radiologist with special interest.
A Pathologist interested and up to date.
A Dedicated Breast Care Nurse.
The Structure of a Breast Unit
Consider adjuvant therapy for all patients after surgery.
Decisions are made following assessment of prognostic and predictive factors and potential benefits and side effects of treatment.
It is recommended that adjuvant therapy starts within 35 days from Surgery, provided wound circumstances allow.
Adjuvant Treatment Cont..
Consider it to support estimation of individual prognosis and
absolute benefit of adjuvant therapy.
NPI; (Nottingham Prognostic Index):
It is also a useful tool, although it does not involve the ER or Her2 status, yet it is simple enough to apply.
The index is calculated using the formula:
NPI = [0.2 x S] + N + G
is the size of the index lesion in centimetres
is the node status: 0 nodes =1, 1-3 nodes = 2, 4+ nodes = 3
is the grade of tumour: Grade I =1, Grade II =2, Grade III =3
>/=2.0 to </=2.4
>2.4 to </=3.4
>3.4 to </=5.4
The goal is to help health professionals make estimates of the risk of negative outcome (cancer related mortality or relapse) without systemic adjuvant therapy, estimates of the reduction of these risks afforded by therapy, and risks of side effects of the therapy
Referrals are assessed, appointment given
Any remotely arranged x-rays/histology should be requested.
Consultation, examination, Mammogram+/- US
Core biopsy / FNA.
Results discussed at Board meeting.
Patient attends Outpatient clinic to
receive diagnostic results and discuss
Overview of Breast care pathway
Further investigations - Primary systemic therapy
Patient attends postoperative clinic to discuss post operative results
Follow up Further surgery Adjuvant therapy
Overview of Breast Care Pathway Cont..
Take Home massages
Proper pre-operative assessment is needed to plan the best surgical approach and achieve maximum disease control with best cosmetic result.
Good communication between the surgeon, the radiologist and the pathologist is also needed.
Ultrasound assessment of the axilla +/- FNA.
Sentinel node biopsy has certainly reduced arm and shoulder morbidity and has reduced hospital stay.
Using predictor factors might identify the subgroup of patients who may not need further axillary surgery in sentinel node +ve cases.
Take home massages cont..
As more and more patients are surviving longer, aggressive management of the primary is warranted.
Oncoplastic surgery has allowed us to be more aggressive in local control without compromising cosmesis.
Minimum margin of 2 mm in DCIS surgery is accepted but not less.
Still, early detection and patient education through awareness programs is the best way towards cure.